Provider Demographics
NPI:1902545320
Name:WALLACE, WHITNEY MORGAN (OD)
Entity Type:Individual
Prefix:DR
First Name:WHITNEY
Middle Name:MORGAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SPINNING WHEEL RD APT 6B
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-7639
Mailing Address - Country:US
Mailing Address - Phone:207-730-9391
Mailing Address - Fax:
Practice Address - Street 1:724 E BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2279
Practice Address - Country:US
Practice Address - Phone:630-633-5631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046011612OtherIL LICENSE NUMBER